Impact of 5‐ASA discontinuation in children with ulcerative colitis on biologic therapy: A propensity score‐matched study

Objectives: 5-Aminosalicylic acid (5-ASA) is recommended as a first-line medication in mild to moderate ulcerative colitis (UC), but indications regarding its use in children with moderate to severe disease treated with biologics are lacking. We aimed to evaluate the impact of discontinuing 5-ASA in children with UC treated with anti-tumor necrosis factor (anti-TNF) anti-tumor necrosis factor (anti-TNF). Methods: Retrospective, multicenter, case–control study of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition inflammatory bowel disease (IBD) study group. Children with UC starting anti-TNF therapy between January 2018 and January 2023 and with a minimum follow of 6 months were included. Those who discontinued 5-ASA (cases) were compared to those who continued mesalamine (controls). A Propensity Score analysis was used to match 1:2 with patients by baseline clinical and demographic characteristics. Every 6 months, during a 2-year follow-up, data on disease flares, IBD-related hospitalization, surgery, need for step-up treatment and acute severe colitis were recorded. Results: Data from 298 children were collected (92 [31%] cases and 206 [69%] controls) and 227 were included in the final analysis after matching (85 [37.5%] cases and 142 [62.5%] controls]. Children who discontinued 5-ASA were at higher risk of courses of steroids (Log-Rank p = 0.003) and hospitalization (p = 0.08). At the multivariate Cox regression analysis, 5-ASA discontinuation was identified as an independent predictor of courses of steroids (p = 0.003) and hospitalization (p = 0.08). Conclusions: 5-ASA discontinuation might negatively impact the clinical course of children with UC treated with anti-TNF. Considering the good safety profile of the drug, continuing mesalamine can be suggested as a prudent approach.